Currency of Practice Hours
(To be filled out by an employer only)
Section 1: Applicant Information
Applicant Name
*
First
Last
ACMDTT #
If known
Practice Name
If any
Applicant Email
*
This is where the applicant receives a completed form to be submitted to the College
Profession
*
Medical Radiation Technology (MRT)
Electroneurophysiology Technology (ENP)
Diagnostic Medical Sonography (DMS)
MRT Specialty
*
Magnetic Resonance Technology
Nuclear Medicine Technology
Radiation Therapy
Radiological Technology
ENP Specialty
*
Electroneurophysiology Technology
DMS Specialty
*
Ultrasound Technologist (Generalist)
Echocardiographer (Cardiac)
Vascular Technologist (Vascular)
Section 2: PRactice Hours
If the applicant has practiced full-time, part-time, or on a casual basis in the specialty, please enter the number of hours practiced.
Practice hours
do not include vacation, sick time, leave of absence or any other paid/unpaid non-practice hours
.
If the applicant has more than one employer or more than one specialty, complete a separate Currency of Practice Hours form for each employer and/or specialty.
If the applicant
did not practice
in the specialty that year,
enter ‘0’
.
If the applicant
was not employed
that year
, enter N/A
.
Record of practice hours
*
Rows
Facility/Organization Name
Number of hours worked in specialty
2026
2025
2024
2023
2022
2021
Section 3: Employer Declaration
Supervisor Name
*
First Name
Last Name
Supervisor Title
*
Supervisor Phone
*
Format: (000) 000-0000.
Supervisor Email
*
Supervisor Signature
*
Date
*
/
Month
/
Day
Year
Print
Submit
Should be Empty: